COMMUNITY JOB CONNECTION REGISTRATION FORM
Date
Enter Today's Date
New ITCDC Client From Web Form
Record Type
ITCDC Record
Client ID
Please enter the last 4 of your SS# and first and last initials. (example 1234FL)
First Name
Last Name
Address
City
State
Zip
Select Your Neighborhood
Please select...
Adair Park
Ashview Heights
Atlanta University Center
Bankhead
Capital City Gateway
Castleberry Hill
English Avenue
Grove Park
Mechanicsville
Non-Atlanta Resident
Other Atlanta Community (not listed)
Peoplestown
Pittsburgh
Vine City
Washington Park
Home Phone
Secondary Phone
Preferred Phone
Please select...
Home
Secondary Phone
Birthdate
Year of Birth
enter all 4 digits - 1964
Race
Please select...
Black - African American
White
Hispanic
Latino
Asian
American Indian
Other
Gender
Please select...
Male
Female
Email
Preferred Email
Please select...
Personal
Do You Use Social Media?
Yes
No
Social Media Do You Use
Please select...
Facebook
Instagram
Linked In
Twitter
Which Services Are You Seeking?
Please select...
Direct Employment
Financial Counseling
Home Ownership Readiness Services
Job Fair Registration
Lawncare
Re-Entry Ex-offender Services
Resume Assistance
Senior Services
Social Services Referrals
Vocational Training
Voter Registration
Westside NET Job Readiness Program
Lead Source
Please select...
Web Form
How Did You Hear About US?
Please select...
AARP
Atlanta Public Schools
Atlanta Workforce Development Agency
CEFGA
City of Refuge
Community Job Connection Bus
Department of Community Supervision
Facebook
Faith Based/Church Organization
Flier
Instagram
Integrity CDC
Internet
Probation/Parole Officer
Quest
Shelter/Transitional Housing
Social Media
Social Service/Government Agency
TV/Radio
Twitter
Walk-In
Word of Mouth
YMCA
Event Name
Profile Data
Profile Date
Enter Today's Date
Client ID (again)
Profile Record Type
ITCDC Profile Record
First Name
Last Name
Are you a Veteran
Yes
ITCDC Program
Please select...
BEAUTIFICATION
BRIDGE/ RE-ENTRY
Community Job Connection (Direct Employment)
DIGITAL LITERACY
GED/ LITERACY
ITCDC CARES
Westside NET
Forklift Certification
Construction
C NA / PCT
CDL (Class A)
Are you currently employed
Yes
What is your current rate of pay?
How long have you been unemployed?
Please select...
0-6 months
1-2 years
3-4 years
5 years or longer
7-12 months
What was your previous rate of pay?
Receiving any Assistance
Yes
unemployment, Food Stamps, etc...
Type of assistance you are receiving
Please select...
Aging Services
Child Care
Child Support Services
Disability
Energy Assistance
Food Stamps
Housing Assistance
Medicaid
Medicare
Mental Health
Other
Peachcare for Kids
SSI
Substance Abuse Services
TANF
Unemployment Insurance
WIC
Hold control key to select more than one answer
Do you have any Mental or Physical Disabilities
Yes
Please Explain Disability
Do you have reliable transportation?
Yes
Explain transportation problems
Do you have a Resume
Yes
Upload You Resume
Identification Section
Valid GA ID
Yes
Valid GA Driver's License
Yes
Drivers License Type
Please select...
Regular (car)
CDL (trucks)
Other
Education
Education Level (s)
Please select...
No High School Diploma or GED
High School Grad
GED
Associate Degree
Bachelor Degree
Graduate Degree
Technical College
Hold control key to select more than one answer
Degree Type
Please select...
AS
BS
Technical
MA
PhD
Other
Hold control key to select more than one answer
Would you like to enter a GED program
Yes
Would you like to receive training
Yes
Training you would you like to receive
Please select...
Administrative/Clerical
Certified Forklift Operator
Child Development Associate
Commercial Driver's License (Class A and B)
Construction
Electricians
Facility Maintenance and Security
Film Production
Financial Services
Food Service
Food Services
HVAC
Information Technology
Medical
Warehouse/Logistics
Welding
Do not select more than 3 choices. (hold control key to select more than one choice)
Employment and Skills
Previous Positions Held
Please select...
Administrative/Clerical
Certified Nursing Assistant
Child Care
Computers
Construction
Custodial/Janitorial
Food Service
Hotel Hospitality or Cleaning
Landscaping
Medical Assistant
Other
Patient Care Technician
Restaurant/Fast Food Industry
Retail
Warehouse/Logistics
(hold control key to select more than one choice)
Position Seeking
Please select...
Administrative/Clerical
Child Development
Computers
Construction
Custodial/Janitorial
Food Service
Hotel Hospitality or Cleaning
Landscaping
Other
Restaurant/Fast Food Industry
Retail
Warehouse/Logistics
Certified Nursing Assistant
Patient Care Technician
Medical Assistant
(hold control key to select more than one choice)
Barriers finding employment
Yes
What are your barriers finding employment
Please select...
Child or elderly care
Criminal History
Lack of educational credential
Long-term unemployed
No valid GA ID or GA Driver's License
Transportation
(hold control key to select more than one choice)
Have you used drugs in the last 30 days
Yes
Are drugs an issue with you
Yes
Would you like drug treatment info
Yes
Will drugs hinder you from employment
Yes
Do you have a Criminal History? (This will not disqualify you for services, it will aid us in placement assistant).
Yes
No
Have you been convicted of a felony
Yes
If yes – when
Do you need Legal Assistance
Yes
Referred By
Name or agency that referred you to this program?
Referral's Phone Number
Offense Type
Please select...
Drugs related offenses
Violent offenses
Theft related offenses
Sexual related offenses
Other
Number of Misdemeanor Convictions
Please select...
1
2
3
4+
Date of most recent Misdemeanor
Number of Felony Convictions
Please select...
1
2
3
4+
Date of most recent Felony
Are you currently on probation?
Yes
Are you bonded?
Yes
Probation’s/ Parole Officer Name
Please explain your probation
Do you rent or own your home?
Are you interested in Home Ownership?
Yes
Contact Information